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Description: A self-educating Q&A casebook aimed at medical students, junior doctors, nurses or those in rural or semi-rural environments who will have to manage surgical emergency & trauma patients.
Written...

A self-educating Q&A casebook aimed at medical students, junior doctors, nurses or those in rural or semi-rural environments who will have to manage surgical emergency & trauma patients.
Written by a British doctor and several of her local and expat colleagues whilst working in South Africa, & based on real cases. Also will be indispensable for doctors from western medicine working abroad in general surgery and trauma for the first time.

A Brit in Rural SA.. The Foreword
I spent my first few minutes by the patient engulfed in a chaotic flurry of chest compressions, blind needles entering the patient’s assumed anatomical large veins and desperately squeezing a bag of crystalloid in what was possibly dead space. “Do everything you can doctor!” – yelled his family who were inexplicably present by the roadside. Injuries incompatible with life; large open skull fracture, multiple fractured limbs, his total blood volume on the floor, two medical students, two shocked paramedics and two British doctors, new to South Africa. In fact I hadn’t even made it to work yet.. I’d just stepped off the plane at Richard’s Bay airport into the result of a road traffic accident involving a young man and his motorbike. My experiences at Ngwelezana Hospital; a Level 2 hospital which provides regional and district services in KwaZulu Natal, have definitely altered my perspectives on healthcare as a doctor. I spent my time bathing in a vast amount of trauma, general emergency and elective cases and witnessed associated afflictions of my patients suffering from the HIV and TB pandemic. The spectrum of diseases and presentations are worth writing and learning about, simply because the population appear to be so resilient despite clinical observations and laboratory results. We all wonder how a patient with a pH of 6.8 and sodium of 178 could still be sat up talking to us, or how a patient with a gunshot abdomen is noted to have several other scars relating to a thoracotomy, two previous laparotomies and a femoral artery exploration, still manages to survive! This book was compiled and written for all those working in rural healthcare in South Africa who manage these type of patients; even at Level 4 where early recognition and treatment of a condition is essential before referral and transfer to other hospitals. Unfortunately triage to survival is reliant on actually making it to hospital, and it is well acknowledged that available and efficient emergency transport is a true limiting factor at times. Inspired by the popular book on Hlabisa Casebook on TB and HIV Medicine, and my love of reflecting, managing and learning from each and every case I see, I present to you this casebook. Acknowledgements and gratitude go to all the patients and their families who participated, some of whom have tragically passed in their experiences illustrated in this book. And finally; to the Ngwelezana Surgery Department staff who have whole-heartedly supported and taught me along the way; I will be back!

Ngwelezana Hospital is a 554 bedded hospital located in coastal Kwazulu Natal, which provides Level 2 trauma care and district, regional and tertiary multidisciplinary healthcare to a population of up to 3 million. Approximately 22 peripheral hospitals refer acute and elective patients to the hospital, which are then, if necessary, referred to hospitals in Durban for further specialist care.

Trauma and emergency services comprise of a specialist Resuscitation Unit in the Emergency Department, 24 hour access to Theatres, Anaesthetists, Trauma and Orthopaedic specialists, a CT scanner, Ultrasound and Radiology services. MRI is also available during working hours. The surgical department comprise of a mix of locally and foreign trained surgeons from intern to Consultant level.

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Trauma Centre Hierarchies
In 2011, the Trauma Society of South Africa published Guidelines for the assessment of trauma centres for South Africa with the intent to promote standardisation of levels of care via accreditation exercises as per request by health care facilities throughout South Africa . Definitions are as follows;

Level
1 – major trauma centre

Qualities and Resources
Able to provide total definitive care Provide leadership in management, education and research 24 hour service Usually receives referrals from Level 2 centres Usually able to provide total definitive care May be responsible for education and research in the region 24 hour service Receives Level 3 and 4 referrals. Provides medical care dependent on staff expertise to a community with no immediate access to Level 2 centres Some may have 24 hour services Reliant on support from Level 1 and 2 facilities Basic life support services before transfer to higher level centres for definitive care

Types of hospitals
University Teaching Hospitals

2 – urban trauma centre

Community facility or academic institution located in urban or rural setting.

3 – community hospital

Rural hospitals

4 – primary healthcare facility

Clinics

This structure is similar for all other non-trauma specialties. In reality, the quality of care healthcare facilities can provide, are variable; largely dependent on current availability of resources and staffing. The referral systems can potentially destruct when a higher-level centre is unable to provide care for a patient from a lower level healthcare facility requiring definitive treatment. Poor communication between these facilities can potentially result in a breakdown of trust, lack of morale and compromise of patient care.

Rural Hospitals in SA
Rural hospitals in South Africa play a hugely important role in primary and secondary level care. Unfortunately, they are often plagued by difficulties with regards to acquiring and retaining a suitably qualified workforce whilst being able to provide appropriate training to develop their broad range of procedural and knowledge base; frequently required to manage community demands effectively. The recruitment of foreign healthcare workers to rural hospitals and the
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creation of community service; a mandatory year for all healthcare professionals to be allocated to select hospitals, is a temporary solution to address staffing levels.

How to read this book and so forth..
There is a deliberate blurred line between levels of healthcare in this book, because in my experience of working in South Africa, one would be heavily reliant on the available knowledge and expertise at your hospital regardless of where you were, and how to manage patients as best you could even at times when referral attempts were unsuccessful. National guidelines or policies are generally designed for environments where it is assumed all resources are guaranteed and available. This is not always relevant in a rural setting. Cases in this book are illustrative examples of management strategies at Ngwelezana Hospital. Each case is assessed on an individual basis, and answers provided are by no means exhaustive. This book will be helpful to you if you have any interest or involvement in the management of surgical patients at any level. In some cases, it may help you to predict or plan ahead for the care a patient may need or receive in a higher level healthcare facility. In my opinion, basic medical principles, diligent thought processes, sensibility, and genuine concern for the patient as their advocate will guide you in their primary patient management.

A pyrexial 14 year old with abdominal pain
A 14 year old female presented with abdominal pain which started centrally and had been present for 5 days. It was associated with vomiting bilious fluid and diarrhoea. The patient had not experienced these symptoms before. There was no significant past medical history and denied pregnancy. She was pyrexial at 37.7 °C, pulse was 114 and BP 99/76. On examination her abdomen was mildly distended with quiet bowel sounds. She had generalised tenderness throughout the abdomen but mostly localised in the RIF. PR was painful yet normal. A vaginal examination was also normal. She the following blood results; WCC of 16.5, Neut - 11.2, Hb -9.9 and Cr- 120, Urea - 9.2, K - 3.0 1. What other blood results would be useful and why? 2. She also gives a history of seeing a traditional healer and taking some medicine prior to coming to hospital. Do you think this has any effect on her presentation? 3. What would your initial management be focused on? 4. What does this image show?

5. What are your differential diagnoses? 6. Her HIV rapid test is noted to be reactive. Would you wait for her CD4 count before proceeding towards a laparotomy?

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A pyrexial 14 year old with abdominal pain answers
1. What other blood results would be useful and why? Amylase to exclude a diagnosis of pancreatitis, which should be at least 3 times the normal value for a diagnosis. An arterial or venous blood gas will indicate the degree of acid base disturbance and lactate concentration which can be used as a reproducible marker for response to resuscitation and high care facility planning. 2. She also gives a history of seeing a traditional healer and taking some medicine prior to coming to hospital. Do you think this has any effect on her presentation? Traditional medicine taken by patients in the form of enemas and oral mixtures, can potentially exacerbate and mask the original presentation in addition to causing severe electrolyte imbalances. It is important to obtain a full history as to what the patient has taken and when. The patient may not always be forthcoming with this information! 3. What would your initial management be focused on? RESUSCITATION! She is currently septic and dehydrated, therefore after assessing her Airway and Breathing, she needs IV access with 1 or 2 wide bore cannulae and a fluid challenge of 2l crystalloid. Targets or end points to fluid resuscitation should be a urine output of >0.5ml per kg per hour, a BP >100 systolic, an improving metabolic acidosis and the patient no longer feeling desperately thirsty! If you are unsure as to the source of the sepsis, ensure you perform adequate tests for culture (ie. urine, blood culture, sputum) and give a broad-spectrum antibiotic such as Co-amoxiclav and/or gentamicin. Her potassium will also need to be corrected in the form of a crystalloid with potassium chloride solution. After adequate optimisation, this patient warrants a laparotomy. At this point an anaesthetist and high care specialist should be called to assess the patient for intra and post op planning. 4. What does this image show? This image shows features of small bowel obstruction. Patients who present late with appendicitis can eventually develop an ileus mimicking small bowel obstruction. The ileus will resolve after addressing the sepsis and replacing the electrolytes to normal. 5. What is the differential diagnosis? Assuming a normal amylase and LFTs, possibilities include Appendicitis, TB abdomen, severe Pelvic Inflammatory Disease, Carcinoid, Typhoid, Bilharzia, (latter can result in spontaneous small bowel perforation) 6. Her HIV rapid test is noted to be reactive. Would you wait for her CD4 count before proceeding towards a laparotomy? Her CD4 result will take a while to return and is irrelevant at this stage. She requires an emergency laparotomy for peritonitis.

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Learning Points:  Treatment of the septic patient should always commence with fluid resuscitation and broad spectrum antibiotics. Review your local sepsis guidelines!  Remember that abdominal sepsis can lead to ileus presenting with obstructive symptoms. A good history will direct you towards the correct diagnosis.

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A pyrexial 14 year old with abdominal pain in OT
You have decided that the aforementioned patient is to undergo a laparotomy. She is currently receiving fluid resuscitation in the resuscitation unit.

1. You will need to gain consent for the operation. Who will you seek this from?

2. What information will you give in order to gain informed consent?

3. It is 2:30am. When would be the best time to perform the procedure? Are antibiotics indicated?

4. What other pre-operative arrangements do you need to make for this patient?

5. You perform a midline laparotomy, and discover widespread peritonitis and plenty of pus, secondary to a perforated appendix. You perform an appendicectomy and wash out the abdomen with warmed normal saline solution. What are your current options?

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A pyrexial 14 year old with abdominal pain in OT answers
1. You will need to gain consent for the operation. Who will you seek this from? She is a 14 year old female, hence, according to HPCSA guidelines, is legally able to consent if she can demonstrate capacity as she is over the age of 12. Consent ideally should also be sought from a parent or guardian. If capacity cannot be demonstrated and parental contact cannot be gained, the consent form should be signed by the Medical Manager or responsible Consultant. 2. What information will you give in order to gain informed consent? This patient clinically has widespread peritonitis, therefore she should be consented for a midline laparotomy. The operation is dependent on findings, hence a ‘Laparotomy +/proceed’ consent should be sought. General intra-operative risks include anaesthetic risks, bleeding, iatrogenic visceral injury. Post-operative risks include pain, wound infection and dehiscence, scar formation, post-op bleeding, abdominal collections, future risk of bowel adhesions and incisional hernias, chest infection and pulmonary embolus. 3. It is 2:30am. When would be the best time to perform the procedure? Are antibiotics indicated? The dehydrated patient needs to be given time to be resuscitated adequately in order to be optimised for theatre. Fluid resuscitation can be guided by a urine output of > 0.5ml per kg per hour or a CVP >8mmHg and an improving metabolic acidosis. Ideally these operations should be performed during working hours when the most help is available. If your patient does not respond to fluid resuscitation, this is a sign of poor prognosis, and one should question whether the patient is likely to survive surgery. In this situation a resuscitative laparotomy may be considered and an anaesthetic opinion should be sought. Once the decision is made to operate, broad-spectrum IV antibiotics – we recommend a 2nd or 3rd generation Cephalosporin, should be administered in attempt to minimise the risk of surgical site infections. 4. What other pre-operative arrangements do you need to make for this patient? A septic, dehydrated patient will require high dependency care post-operatively for inotropic support +/- ventilation until the systemic inflammatory response improves, hence it is essential to seek a bed pre-operatively by discussing it with the appropriate doctors. If there are none available in your hospital, you may have to consider transferring the patient out to a hospital with a high care facility. The anaesthetist needs to be aware of the patient’s history and clinical condition and should also be involved in the management of pre-operative resuscitation. A CXR and recent blood results including an arterial blood gas should be available. 5. You perform a midline laparotomy, and discover widespread peritonitis and plenty of pus, secondary to a perforated appendix. You perform an appendicectomy and wash out the abdomen with warmed normal saline solution. What are your current options?

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In most cases of a ‘dirty abdomen’ (i.e enteral or purulent contamination causing widespread peritonitis), we prefer to leave the abdomen open in view for a semi-elective closure within the next 48 hours in which they can be stabilised and resuscitated further in a high care facility. We use an op-site sandwich mechanism (show diagram). These patients are usually left on the ventilator, hence the availability of a high care facility with ventilatory support is essential. Other options include primary closure of the rectus sheath with or without skin closure. We find there is a high risk of wound infection and post-operative ileus in these patients, hence close post-operative monitoring is essential. Learning Points  Plan for post operative care before you operate  Op-site sandwich or Bogota bag is a reasonable option when there is widespread contamination and you feel that the patient will require a relook in the next few days. Further Reading
Health Professionals Council of South Africa. (2007) Seeking Patients Informed Consent – The Ethical Considerations (Second Edition) http://www.hpcsa.co.za/downloads/conduct_ethics/rules/seeking_patients_informed_consent_ethical_considera tion.pdf Accessed December 2011 Van Ruler et. Al (2007) JAMA. Comparison of on-demand vs planned relaparotomy strategy in patients with severe peritonitis: a randomized trial. JAMA. Aug 22;298(8):865-72.

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A simple epigastric stab wound?
A 25 year old male sustains a single stab wound to the epigastrium and is brought into his local hospital shortly afterwards. 1. How would you initially evaluate and manage this patient? 2. You are concerned as to what the depth of his injury is. What options do you have to determine this in the casualty setting?

3. He undergoes a laparotomy for a stomach laceration, which is closed primarily and is sent to the ward. Two days later he becomes progressively tachycardic and pyrexial. His abdomen is moderately distended and tender throughout. He has a few coarse crepitations at the bases of his lungs. His repeat bloods show an Hb of 8.8, WCC 20 with normal U&Es. What are the possibilities and how would you proceed?

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A simple epigastric stab wound answers
1. How would you initially evaluate and manage this patient? Follow the ATLS protocol for initial primary evaluation of all trauma patients. If the wound is bleeding, it should be packed or pressure dressing applied. There is no place for suturing in initial resuscitation. Ensure an NG tube is placed for stomach decompression, and insert a urethral catheter. 2. You are concerned as to what the depth of his injury is. What options do you have to determine this in the casualty setting? Probing of wounds is generally unreliable and can introduce further contamination or damage in the process. If the patient is tender distally to the wound site, this would warrant further investigation. In the casualty setting a FAST scan would identify the presence of a significant amount of free fluid in the abdomen (blood, ascites, enteral contents). It is less sensitive for stab wounds and operator dependent. Other options include CT scanning with IV and oral contrast, which is sensitive for free fluid, but not specific for its source. Hollow viscus injuries can also be missed on a CT scan. A diagnostic laparoscopy or laparotomy should be considered if concerns remain. 3. He undergoes a laparotomy for a stomach laceration, which is closed primarily and is sent to the ward. Two days later he becomes progressively tachycardic and pyrexial. His abdomen is moderately distended and tender throughout. He has a few coarse crepitations at the bases of his lungs. His repeat bloods show an Hb of 8.8, WCC 20 with normal U&Es. What are the possibilities and how would you proceed? Post-operative complications include: Post-op haemorrhage, leaking from primary repairs, ileus, chest infection and missed injuries. Do not forget other potential post op complications including pulmonary embolus, chest infections and SIRS. Re-evaluate the patient in a structured fashion (ATLS/ACLS) and allow that to guide you as to what further management the patient requires. If gross gastric contamination was discovered in the first instance, it may have been prudent to leave the abdomen open with an Op-site sandwich or equivalent and wait for the next clinically appropriate time to perform a re-look and washout prior to primary closure. What happened next.. This patient was transferred from a peripheral hospital where he had the first laparotomy and subsequently deteriorated on the ward. His re-laparotomy revealed 1 litre of haemoperitoneum and an intact anterior stomach laceration, which had been sutured; however he also had 4 other missed injuries including a posterior stomach laceration, two transverse colon and a mesenteric injury. After several months in and out of ICU, and 2 further operations complicated by an enterocutaneous fistula and spontaneous enterostomies, he eventually died of chronic sepsis.

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Learning Points  A negative FAST scan performed for a penetrating wound does not exclude significant injuries.  All trauma operations should be performed in a centre with appropriately trained trauma surgeons and supporting high care facilities. If this is not immediately possible, the patient should be stabilised (ie intra-abdominal packing for massive haemorrhage) and transferred at the earliest opportunity. Further reading
Ng A, Trauma Ultrasonography (2001), Trauma.Org Website http://www.trauma.org/archive/radiology/FASTfast.html Accessed December 2011 Chapter 1 – Initial Assessment and Management. ATLS Advanced Trauma Life Support for Doctors (8th Ed.) (2008) American College of Surgeons

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A tachypnoeic polytrauma case
A 23 year old male was a passenger in a local bus accident where the bus rolled at speed. He sustained multiple soft tissue injuries including abrasions to his face, lumbar region and right knee. There was no history of loss of consciousness and he appears alert with a GCS of 15. 1. How would you initially evaluate and manage this patient?

2. On examination of his breathing, you notice he has a respiratory rate of 40, with saturations of 84% on air. He has subcutaneous emphysema of his right anterior hemithorax with dull percussion notes at the bases bilaterally. He also has an odd sucking chest wall movement with see-sawing of his abdomen. What are the clinical possibilities and how would you treat them?

3. You have treated the patient appropriately and his oxygenation has improved to 93% on a non-rebreathe mask providing 100% oxygen. You order an ABG with the following results. What does it show? pH 7.28 pO2 – 12.6kPa pCO2 -7.5kPa HCO3 – 24.5 BE – 4

4. What further investigations should the patient have?

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5. What investigation is this and what does it show?

6. How and where should this patient be managed?

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A tachypnoeic polytrauma case
1. How would you initially evaluate and manage this patient? Evaluate this patient using ATLS protocol including C-spine control.

Answers

2. On examination of his breathing, you notice he has a respiratory rate of 40, with saturations of 84% on air. He has subcutaneous emphysema of his right anterior hemithorax with dull percussion notes at the bases bilaterally. He also has an odd sucking chest wall movement with see-sawing of his abdomen. What are the clinical possibilities and how would you treat them? Clinical suspicion for a tension pneumothorax should be high, hence the treatment of 2 nd intercostal space needle thoracocentesis with subsequent chest drain should be considered. Subcutaneous emphysema on the chest wall indicates a likely pneumothorax with a possible concomitant haemothorax, hence waiting for a CXR to confirm these suspicions before the procedure is not always necessary, especially in an unstable patient. The unusual chest wall movement is likely due to a flail chest segment. Flail chest occurs when >2 ribs are broken in 2 or more places, leaving a chest wall segment which moves paradoxically (in-drawing of the chest on inspiration and vice versa), subsequently increasing the work of respiration. The size of the flail chest varies dependent on the number of ribs involved and can potentially involve the sternum and the opposite hemithorax. 3. You have treated the patient appropriately and his oxygenation has improved to 93% on a non-rebreathe mask providing 100% oxygen. You order an ABG with the following results. What does it show? pH 7.28 pO2 – 12.6kPa pCO2 -8kPa HCO3 – 24.5 BE – 4 The ABG shows a type 2 respiratory failure with respiratory acidosis. Although the pO2 is within normal limits, one should remember that this value is for people breathing an fiO2 of 0.21 (room air). This patient is on 100% oxygen, so you would expect a much higher pO2 in a normally functioning lung. 4. What further investigations should the patient have? The patient is too unstable to transfer to the radiology department, hence requesting a portable CXR is adequate at this time. It can be used to ensure the chest drains are in place, the amount of residual haemopneumothoraces, and also any rib fractures which sometimes can be difficult to identify. 5. What investigation is this and what does it show? These are images of an axial and coronal CT chest on the lung window setting. The axial image demonstrates right sided subcutaneous emphysema with a moderate right sided and very small left sided pneumothorax. There are significant lung contusions mainly involving the left lung on this slice. The coronal view of the same patient showing the right and left main bronchi and aforementioned lung contusions.
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6. How and where should this patient be managed? Due to the extent of his injuries illustrated by the pulmonary contusions and his deteriorating respiratory acidosis, the patient is likely to require airway intubation and mechanical ventilation in the form of BiPAP. Discussion with a high care unit dedicated to Trauma is essential for the management of this patient, as he is also at high risk of developing a pneumonia +/- ARDS. In patients who are more stable with less severe underlying pulmonary contusions, tailored oxygen administration and CPAP may be adequate in combination with intravenous fluid resuscitation and analgesia in the form of a pleural block, epidural or systemic opiates. Learning Points   The presence of flail chest points towards the severity of the underlying lung contusions caused by high energy impact forces. This condition may subsequently result in respiratory failure. These patients can deteriorate quickly, hence transfer to the nearest Trauma centre where ventilator support is available is essential.

Abdominal pain in a heavy smoker
A 65 year old heavy smoker presents with a 1 day history of sudden onset severe abdominal pain in the epigastrium. Pain is constant. No prior history. He takes painkillers occasionally for aches and pains, otherwise previously well. He drinks ‘socially’. His pulse rate is 104 regular, BP 105/62, temperature -36.9°C, saturations 92% on air. On examination he is mildly dehydrated. Chest sounds clear. Abdomen is generally tender with guarding in the epigastrium. 1. What initial investigations would you order for this patient? 2. What is your differential diagnosis? 3. What is this form of imaging and what does it show?

5. Further imaging was arranged. What imaging is this and what does it show?
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Abdominal pain in a heavy smoker

Answers

1. What initial investigations would you order for this patient? During resuscitation of this patient you would order FBC, U&Es, LFTs, Calcium, Magnesium, Phosphate and amylase. An erect CXR is important to exclude pneumoperitoneum as a result of a viscus perforation and identify any concomitant thoracic pathology. Cardiac pathology cannot be excluded, therefore an ECG is also paramount. If available, a venous or arterial blood gas may be of benefit for guidance of fluid resuscitation and predicting necessity for high care. 2. What is your differential diagnosis? Acute gastritis, perforated peptic ulcer disease/gastric carcinoma, acute coronary syndrome, acute pancreatitis, AAA, pneumonia 3. What is this image and what does it show? This is a PA film of an erect CXR. The main questionable abnormality is the appearance of two diaphragmatic markings separated by air. The air fluid level of the gastric bubble has a shadow where you would expect to see a relatively linear demarcation between fluid and air. These discreet signs may lead you to consider the possibility of pneumoperitoneum.

What is the likely diagnosis and how would you manage this patient? With a raised amylase of 983, acute pancreatitis should be considered as one of the primary diagnoses. Amylase in acute pancreatitis should usually be 3 times the normal value. However remember that there are several other causes of hyperamylasaemia which should be placed into clinical context; salivary disease (ie. parotitis), hepatorenal failure (decreased clearance), intestinal disease (ie. visceral perforation, inflammatory diseases, mesenteric infarction), ovarian pathology (ie. ruptured ovarian cysts), trauma, acidosis and ectopic amylase production. LDH is a non-specific marker of tissue degradation. It can be raised in numerous pathologies including MI, haemolysis, empyema, pneumocystis jiroveci pneumonia. It is also used in Glasgow Scoring for acute pancreatitis. Despite a raised amylase, if there is any doubt as to the diagnosis, further imaging should be considered. 5. Further imaging was arranged. What imaging is this and what does it show? This is an axial CT scan in the arterial phase. It shows free fluid around the liver. In order to clearly identify free air on a CT scan, you should use the lung view window and inspect around the level of the umbilicus, superiorly. On the lung view image, free air can be clearly seen. The septation can easily be mistaken for valvulae conniventes in bowel, when in fact it is the falciform ligament. There is a pocket of air seen clearly on the lung view around in the stomach, which is the site of perforation of a gastric ulcer on the lesser curvature.

What happened next.. The patient had 2 litres of free fluid of gastric contents in the abdomen which was thoroughly washed out. The ulcer was biopsied, and a naso-jejunal tube secured by holter was inserted to provide nutrition in the immediate post-op period. An omental patch was secured over the perforation and the abdomen was closed. The patient was sent to the ward post-operatively however developed complications of a wound dehiscence from a wound infection, bowel evisceration and subsequent nosocomial pneumonia from which he demised.

Learning Points  If the diagnosis is doubtful and the patient is stable, organise further definitive imaging at the nearest convenience.  There are a multitude of causes for hyperamylasaemia; don’t get caught out by taking a thorough history from the patient.

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Male with dysuria and subsequent scrotal insult
This HIV negative 26 year old male had some difficulty passing urine for a few days and developed urinary retention. He was admitted into hospital and a supra-pubic catheter was inserted which drained slightly cloudy urine. He then developed a sore on his scrotum which then subsequently spread. 1. What does this picture show? What is the diagnosis?

2. What is the likely aetiology? 3. What would your initial and definitive management be? 4. Would you expect testicular involvement? 5. You have instituted your initial and definitive management successfully. What further intervention do you think he may require?

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Male with dysuria and subsequent scrotal insult

Answers

1. What does this picture show? What is the diagnosis? This picture shows Fourniere’s gangrene of the scrotum. It has partial involvement of the perineum and superficial inguinal regions bilaterally. 2. What is the likely aetiology? Fourniere’s gangrene is the result of a synergistic infection of anaerobic (Bacteroides, Clostridium) and aerobic (ie. E. Coli, enterococcus) bacteria. It usually occurs secondary to localised skin trauma or a perianal or urinary tract infection. Watch out of the characteristic putrid smell! 3. What would your initial and definitive management be? It is important to ensure the patient is fluid resuscitated as necessary, bloods and blood cultures should be sent and the patient should be administered broad spectrum antibiotics such as Augmentin and Gentamicin. He then requires total debridement and exploration of the wound. The key to debridement is to cut down to bleeding tissue. If its not bleeding, its dead! 4. Would you expect testicular involvement? The blood supply of the scrotal skin is largely from the internal pudendal artery which is a branch of the internal iliac artery, whereas the testicular arteries originate from the abdominal aorta around the level of the renal arteries. The lymphatic drainage follows similar patterns (superficial inguinal for the scrotum, and para-aortic for the testicles), hence it is uncommon for testicular involvement unless direct spread has occurred. 5. You have instituted your initial and definitive management successfully. What further intervention do you think he may require? There will be loss of a large surface area of skin and perhaps some soft tissue, hence will likely need a skin graft. Split skin grafting may be a temporary option in the rural setting, but for the best cosmetic options, it should be referred to a Plastic Surgery specialty.

Learning Points  Institute broad spectrum antibiotics and resuscitation early in these patients. Don’t wait for them to become shocked!  Testicular involvement is rare, yet it is essential to counsel and consent the patient for a possibility of orchidectomy.  Discuss cosmetic options with Plastic Surgery Further Reading Reynard et al. Oxford Handbook of Urology (2005), OUP Oxford, Oxford

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Anterior stab wound to the neck
A patient walks into casualty having sustained a single stab wound to the neck as shown. Having been evaluated by the casualty doctor and subsequently sutured up, there seems to be no active bleeding and observations are normal. The patient is talking but there is palpable subcutaneous emphysema around the neck.

1. How would you categorise the location of the stab wound and which category would this stab be in? 2. Why may he have subcutaneous emphysema?

3. What further investigations are necessary?

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Anterior stab wound to the neck

Answers

1. How would you categorise the location of the stab wound and which category would this stab be in? Zone 1 Anatomical Location Between the jugulo-sternal notch / clavicles, to the level of the cricoid cartilage Between the cricoid cartilage and the angle of the mandible Above the angle of the mandible to the skull base At risk structures Great vessels of the thorax, lung apices, common carotids, jugular veins, trachea, oesophagus, C-spine, spinal cord and vessels Carotids, trachea, larynx, pharynx, jugular, C-spine and spinal cord Carotids, jugular veins, parotid gland, CN IX-XII, vertebral bodies

2 3

Diagram of Anatomical Location of Neck Zones for Trauma

This stab wound is either just below or at the level of the, which would categorise it as a Zone 1 stab wound. 2. Why may he have subcutaneous emphysema? He may have sustained an injury to a structure containing air (ie. Larynx, hypopharynx, lung, oesophagus). 3. What further investigations are necessary? He requires an erect CXR to exclude a haemopneumothorax which may require a chest drain. An FBC is necessary to exclude acute anaemia secondary to a concealed vascular injury. A gastrograffin swallow should be considered in a rural setting to exclude

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oesophageal injury, but even in these situations, small injuries could potentially be missed. Upper GI endoscopy is an option, however small lacerations can easily be missed. All stable patients with Zone 1 injuries should ideally have a CT angiogram to exclude vascular injuries. U&Es will be required in the elective setting as IV contrast is excreted via the renal system may already be impaired on a background of pre-existing disease. In an emergency, one may argue against waiting for these results if the condition is time sensitive.

Learning Points  Penetrating neck injuries can involve plenty of important structures. Zone categorisation enables you to identify which ones are at risk.  Zone 2 vascular injuries can be excluded by Doppler ultrasonography with trained personnel, otherwise Zone 1 and 3 vascular injuries need to be excluded using CT angiography in stable patients at the nearest convenience

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An old gunshot to the chest
A patient presents to clinic with a left sided peri-clavicular swelling. It claims he sustained a gunshot injury about a year ago. Having sought medical attention, he was diagnosed with a haemopneumothorax which was drained, and then subsequently discharged home. The swelling has been present since the trauma. He is otherwise well. On examination he as a large swelling surrounding the healed gunshot entrance wound which extends to the supraclavicular fossa. He has no apparent musculoskeletal or upper limb neurological problems. He appears to have no exit wound.

1. What signs would you look for if you were concerned about a vascular injury? How could you further categorise these? 2. The patient has a few signs of vascular injury as you have described above. What further investigations would you organise in this situation. Would you change your management if he presented acutely with evidence of ongoing haemorrhage? 3. What is the likely diagnosis in this case? 4. What would be your management options in this case? 5. Where is the likely location of the bullet?

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An old gunshot to the chest

Answers

1. What signs would you look for if you were concerned about a vascular injury? How could you further categorise these? These can be placed into two categories; Hard Signs Visible haemorrhage Palpable or visible pulsation Bruit and/or thrill Signs of distal ischaemia Expanding haematoma Soft Signs Anatomical location of a vessel at site of injury Distal decrease or absence of pulsation Neurological pathology distal to site of injury Bony injury

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   

2. The patient has a few signs of vascular injury as you have described above. What further investigations would you organise in this situation? Would you change your management if he presented acutely with evidence of ongoing haemorrhage? This patient has a large pulsatile left supraclavicular mass with a bruit on auscultation. He has a relatively decreased pulsation in the left arm compared to the right, but no signs of distal neurological abnormality. In this outpatient setting it would be important to organise a CT angiogram to determine which vessels are involve and the extent of the injury. This information would be used to plan management options. An ultrasound Doppler is also a fairly rapid and cheap way to evaluate the extent of the injury in a rural setting but is operator dependent. If he was actively bleeding, you would try to avoid the “donut of death” (CT scanner) and go straight for a left subclavian artery exploration. 3. What is the likely diagnosis in this case? Pseudoaneurysm of the subclavian artery. The vein can also be involved. 4. What would be your management options in this case? In this elective setting, if left alone there is potential for aneurysmal rupture, distal embolus and upper limb ischaemia. Other options include a subclavian artery exploration using a supra and infraclavicular approach without cutting the clavicle. Always consent the patient and prepare for the possibility of a reverse saphenous vein graft. Interventional radiologists may be keen to attempt to embolise or coil the artery in available centers. Ensure you have an adequate amount of blood cross match ready on standby!

5. Where is the likely location of the bullet?

Learning Points  Do not put unstable patients into the “donut of death”  Prepare the patient for possibility of reverse saphenous venous grafting.  Send these patients to the nearest vascular or trauma centre as soon as possible.

Urinary retention in an 8 year old boy
This 8 year old boy presented with this problem having had a 4 day history. He was given antibiotics at his local clinic, but the problem hasn’t resolved. He was complaining of dysuria and his mother says he hasn’t passed urine in the last 18 hours.

1. What is your diagnosis? 2. What is the aetiology of this condition? 3. What are the complications if this condition is left untreated? 4. What are your management options?

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Urinary retention in an 8 year old boy
1. What is your diagnosis? Paraphimosis

Answers

2. What is the aetiology of this condition? Paraphimosis occurs when the foreskin has been pulled back and trapped behind the glans of the penis. It can occur as the result of urethral instrumentation, examination or cleaning, secondary to an erection or sexual intercourse. 3. What are the complications? The constrictive band leads to swelling of the foreskin and secondary swelling of the glans itself, sometimes associated with ulceration of the skin (sometimes confused with an infective process). This process can potentially lead to distal ischaemia of the penis and/or urinary retention, hence is a urological emergency. 4. What are the management options? If the patient has signs and symptoms of acute urinary tract obstruction, it is important to attempt to relieve this immediately. The patient should be cannulated and given some IV analgesia in the form of an opiate and/or paracetamol if available. Attempt to manually reduce the paraphimosis in casualty should be the first option. A dorsal penile block using 5-10mls of 1-2% lignocaine (dependent on age and weight) should be administered. This can also be combined with a dose of 0.25-5% bupivacaine (Marcaine) for a long-lasting effect. Marcaine solutions containing adrenaline are contraindicated. Hold the foreskin with both hands at the level of the constriction band and gently but firmly apply persistent traction in attempt to reduce the swelling. It can take quite a few minutes to achieve success. If the patient is unlikely to tolerate this procedure, or if it fails, a dorsal slit or full circumcision is a final option.

Learning Points  Paraphimosis is a urological emergency and should be treated as soon as possible  If successfully reduced, the patient should be counselled as to its cause. An elective circumcision is an option but not mandatory.

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Man with a facial swelling
This patient presents to you with a 3 week history of this facial swelling. Pus is aspirated from the swelling by one of your colleagues and advises that he needs to go to theatre for a formal incision and drainage. 1. What are the potential aetiologies for this face abscess? 2. What factors would you want to consider whilst planning this operation?

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Man with a facial swelling

Answers

1. What are the potential aetiologies for this face abscess? Dental abscess – oral cavity shoud be inspected if possible. Orthopantogram should be performed and a dentist opinion sought TB cold abscess Idiopathic 2. What factors would you want to consider whilst planning this operation? This patient has a large abscess cavity with possibility of communication with the airway and subsequent risk of aspiration. A lateral soft tissue neck XR may show tracheal identation or compression if there is a risk of airway compromise. Discuss this patient with the anaesthetist as he may require post-op ventilation and regular airway toilet for a period of time until the cavity has completely drained. The site of incision is important. Ensure that regions containing certain facial nerves are avoided ie. the marginal mandibular nerve. A pus swab should also be taken and this result should be followed up. The patient should also be screened for HIV and Diabetes which are common causes for being Immunocompromised in the Zululand population.

Post chest stab pain
This gentleman was stabbed in the back by some ‘gangsters’ whilst at home. He attends his local clinic where they suture his wound closed. During the following days he experiences pain on the right side of his chest so he is directed to hospital.

On examination he has equal air entry bilaterally with good chest expansion. Saturations are 98% on air with a respiratory rate of 22 breaths per minute. The rest of the observations are within normal limits. 1. What are the possibilities for the cause of his chest pain?

2. What investigation would you organise primarily?

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Post chest stab pain continued…
3. What do these CXRs show?

4. You decide to take this patient to theatre. What position would you place him, what are the possible complications and what post-operative procedure would you perform?

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Post chest stab pain

Answers

1. What are the possibilities for the cause of his chest pain? As he only had primary suturing performed at the clinic, they may have missed several acute pathologies; pneumothorax (tension or simple!), haemothorax, associated rib fractures and possible lung contusions. It is also important not to forget pulmonary embolus as a cause for chest pain post trauma. Cardiac injury is always a possibility, hence an ultrasound of the heart to exclude a haemopericardium should be organised at the nearest convenience. 2. What investigation would you order primarily? An erect CXR 3. What do these CXRs show? This CXR shows a knife blade located in the lateral right hemithorax. There is no obvious associated haemopneumothorax visible on these films. The mediastinum appears normal. 4. You decide to take this patient to theatre. What position would you place him, what are the possible complications and what post-operative procedure would you perform? It is safer to remove this blade under anaesthetic due to its size and the presence of serrated edges which may cause further bleeding. In the event of any complications occurring the patient should be positioned in the left lateral position in preparation for a posterolateral thoracotomy.

What happened next.. The knife was successfully removed by extending the wound incision inferolaterally by a few centimetres, and dissecting down to the knife handle. The knife blade was then removed with pliers. A chest drain was inserted post-operatively to monitor for secondary bleeding and to drain the chest cavity. He was discharged home a few days later after removal of the drain without complications

Learning Points  All patients with thoracic injuries should have a plain film chest XR regardless how ‘well’ the patient looks.  Removing foreign bodies from the thorax is potentially very dangerous due to the proximity of several vascular structures, therefore it is advised to do this under controlled conditions in the operating theatre. Always prepare for the worst case scenario!

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A left sided red tap
A 30 year old male was stabbed anteriorly in the left hemithorax 3 rd intercostal space laterally. He presented with a pulse of 100, BP 105/72, saturating at 92% on air. The wound did not appear to be actively bleeding but he had some subcutaneous emphysema. After administering oxygen, inserting a wide bore cannula, taking appropriate blood and starting a fluid challenge, a left sided chest drain was inserted which immediately drained 500mls of blood.

1. Describe what the CXR shows. 2. Describe where you would insert a chest drain and how you would perform the procedure. 3. In the subsequent hour he drains another 300mls of blood. What concerns do you have? 4. What would be your management options?

A left sided red tap

Answers

1. Describe what the CXR shows. The CXR shows a large left sided haemopneumothorax nicely delineated with an air-fluid level at the top 2. Describe where you would insert a chest drain and how you would perform the procedure. In trauma situations, a large bore chest drain (approximately 32G) should be inserted in the ‘triangle of safety’ which is bordered by the anterior border of latissimus dorsi, the lateral border of pectoralis major, the inferior border is an invisible horizontal line at the level of the nipple or 5th intercostal space, and the superior border is the apex of the axilla.

Borders of the ‘Triangle of Safety’

The patient should be consented adequately for the procedure. Local anaesthetic should be infiltrated after a bleb in the skin just above the rib and then deeper into the soft tissues down to the parietal pleura. Aspiration and injection can be performed until either air or fluid from the pleural space is aspirated. Make an incision with a blade down to the subcutaneous fat large enough to admit the chest drain. Then use blunt dissection with forceps to separate muscle fibres and moderate amount of force until breach of the parietal pleura is achieved. Remember to perform this procedure just superior to the rib as the intercostal neurovascular bundles run inferiorly. Perform a finger sweep to break down any adhesions and to ensure the cavity is free. Grip the proximal end of the chest drain with forceps and

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clamp the distal end. Insert the drain, usually superiorly for pneumothoraces and inferiorly for haemothoraces. Suture the drain to the skin either using a non-absorbable suture, then connect it to an underwater chest drainage system. If a large amount of haemothorax is anticipated, it is advised to use heparinsed saline in the bottle in the event it may need to be re-transfused if there is a massive haemorrhage. 3. In the subsequent hour he drains another 300mls of blood. What concerns do you have? Patient may have a significant vascular injury. There is also a possibility that you may have inadvertently inserted your drain into the heart (a well documented complication!), however this would be very obvious on initial insertion of the chest drain. 4. What would be your management options? If the patient is relatively stable, you should order blood for cross match and consider a CT angiogram to determine the site of the vascular injury. The patient should be continuously monitored in a high care setting. If the patient continues to bleed >200ml per hour from the drain, and/or becomes haemodynamically unstable, it would be prudent to perform a thoracotomy.

Learning Points  Indications for thoracotomy include a chest drain output of 200 ml per hour or more for 3-4 hours and/or an initial drainage of 750mls or more.  Insert heparinised saline into your chest drain bottle in the event you may need to autotransfuse your patient if a massive haemothorax is anticipated. Further Reading
ATLS Advanced Trauma Life Support for Doctors (8th Ed.) (2008) American College of Surgeons

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Haematuria after blunt abdominal trauma
A 29 year old female was in the backseat of a car, which impacted against a tree. You assess her in casualty using ATLS principles and your clinically significant findings were frank haematuria on urinary catheterisation, which subsequently cleared, and some pelvic tenderness. Observations were otherwise normal. 1. What is this image? How would you perform it and what does it show? What are its limitations? 2. What is the likely differential diagnosis for the haematuria in this case?

3. Which other investigations could you arrange to image the rest of the renal tract? 4. What would be your management for the patient?

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Haematuria after blunt abdominal trauma
1. What is this image? How would you perform it and what does it show? What are its limitations? This image is an AP retention phase cystogram, which is performed using LODOX imaging. 250mls of urograffin is instilled into the bladder and then clamped. An AP and oblique film is taken in retention. The clamp is released, and a post void film is taken. This retention phase film shows contrast localised in the pelvis, indicative of an extraperitoneal bladder rupture. The post void film for this patient showed some contrast remaining in the pelvis post-void. The images taken should be focused on the entire abdomen in order to identify an intraperitoneal bladder rupture where extravasation of contrast may be seen between bowel loops and/or tracking in the paracolic gutters. The bowel gas patterns may also be somewhat higher than usual. Not clearly visualised on this image, are inferior pubic ramic fractures. These can be associated with other pelvic injuries involving the renal tract 2. What is the likely differential diagnosis for haematuria in this case? Haematuria can be secondary to injury to any part of the renal tract. It is difficult to determine the site from catheterisation alone. 3. Which other investigations could you arrange to image the rest of the renal tract? A CT IVP with intravesical contrast. A FAST scan may identify free fluid in the abdomen and allow direct imaging of the kidneys depending on operator skills. 4. What would be your management for the patient? The patient can be managed conservatively using urinary catheterisation for up to 2 weeks. A repeat cystogram can be performed before the catheter is removed to confirm the bladder has healed. Learning Points  Maintain a high suspicion for lower urinary tract injuries in patients sustaining pelvic fractures  A cystogram can easily be performed in a casualty setting. Ensure a large amount of urograffin is instilled under pressure and adequate retention and post void films of the abdomen are taken in order to differentiate between an extraperitoneal and intraperitoneal bladder injury, which are managed differently.  If in continuing doubt, arrange a contrast enhanced CT cystogram which may also be used to identify other intra-abdominal and bony injuries. Further Reading
Arellano RS et al. ACR Appropriateness Criteria® suspected lower urinary tract trauma. http://www.ngc.gov/content.aspx?id=15773 Reston (VA): American College of Radiology (ACR); 2009 Accessed December 2011

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Delayed presentation post MVA
A 25 year old male was a passenger in a vehicle that suffered lateral impact from an oncoming vehicle. He presented to a clinic with a few minor scrapes and muscle ache shortly afterwards, however was subsequently discharged home. 3 days later he presented to casualty with increasing localised left upper quadrant abdominal pain. On examination he was alert, with a pulse of 110, BP 115/70, RR 24 and apyrexial. He had localised tenderness in the left hypochondrium.

1. What would your initial management of this patient be? 2. What definitive investigations would you order? 3. In the event of a splenic injury, what factors would you consider which may preclude surgery? 4. What should the patient be counselled about post splenectomy?

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Delayed Presentation post MVA

Answers

1. What would your intial management of this patient be? Despite the delayed trauma presentation, initial management should follow the primary survey in accordance to ATLS guidelines. FBC, U&Es and a Type and Screen should always be taken during the primary survey to evaluate for blood loss and dehydration and prepare for transfusions requirements. A blood gas will give you the general metabolic status of the patient including a lactate. 2. What definitive investigations would you order? The impact of blunt abdominal trauma can leave a Pandora’s box for many possibilities. Your differential diagnosis should include solid or hollow visceral injuries, including delayed haemorrhage. In an acute setting a FAST scan will identify the presence of free fluid in the abdomen but will not specify the source. Ultrasound if available will help identify solid visceral injuries quickly, however in this scenario, a contrast enhanced CT scan is perhaps the most specific. 3. In the event of a splenic injury, what factors would you consider which may preclude surgery? 1. Signs of ongoing haemorrhage despite transfusion – transient or non responder 2. Worsening abdominal pain 3. Haemodynamically unstable patient 4. Evidence of an infected haematoma (if not amenable to percutaneous drainage) 4. What should the patient be counselled about post splenectomy? Trauma patients who have undergone splenectomy should be vaccinated against encapsulated organisms – Streptococcus pneumonia, Haemophilus B, Neisseria mengitiditis. As the patient is likely to be immuncompromised as a result of the extent of trauma, it is safest to administer approximately after 2 weeks or thereafter. Some centres give the patient low dose Penicillin prophylaxis daily to be taken for the rest of their life. It is also reasonable to educate the patient that if they begin to feel ill, they should seek medical attention as soon as possible. Learning Points  Free fluid seen in a Trauma patient, in the absence of solid visceral injury, requires an exploratory laparotomy.  Some solid visceral injuries can be managed conservatively, however these patients need close monitoring.

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Patient with a wrist laceration
A 45 year old female was attacked by her boyfriend in a domestic argument and sustained a laceration to her wrist which began to bleed heavily. She attended the casualty unit.

1. How would you primarily assess this patient?

2. This patient is taken to theatre and the wound is explored. There appears to be a radial artery transection. What operative options do you have?

3. Who else should be present during the procedure?

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Patient with a wrist laceration

Answers

1. How would you primarily assess and manage this patient? All trauma patients should be assessed as per ATLS protocol. Her bloods should involve an FBC, U&Es and Crossmatch. Signs of perfusion distal to the injury should be documented. Neurology should also be assessed and documented. An isolated vascular injury is very rare and is usually accompanied by nerve and tendon injuries. 2. This patient is taken to theatre and the wound is explored. There appears to be a radial artery transection. What operative options do you have? Your choices are dependent on the general clinical state of the patient, (ie whether you have time to be performing distal salvageable vascular repairs), and the presence of good collateral flow from the ulnar artery. If the latter is present, the radial artery can be tied off without consequences. If the ulnar artery is also injured, an intra-operative decision should be made to determine which vessel could be repaired with a good outcome.

3. Who else should be present during the procedure? Orthopaedic / Hand surgeons. There will be a high likelihood of associated flexor tendon and/or nerve injuries.

Learning Points   It is essential from a clinical and legal standpoint to document neurovascular status of the patient on admission Restoration of hand function requires multidisciplinary input, which continues after surgery.

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Snake bite and black
A 5 year old boy is bought to casualty with a history of snakebite. The bite occurred three hours ago on his right hand, and now his arm is very painful and swollen. His observations are Pulse 110, BP -105/80, RR-28. His mother tells you that the snake appeared to be a green mamba, that he has no allergies, and no past medical history. Examination reveals a tender right arm swollen to the level of the elbow There are two puncture wounds over the first dorsal webspace associated with a small area of blistering (2cm x 1cm).    What type of venom is most likely in this case? The casualty sister asks if she should fetch the antivenom. How will you decide if you need antivenom and how will you administer it? What late complications should you be vigilant for?

2. How will you decide if you need antivenom? Antivenom is a purified immunoglobin derived from horses who are repeatedly envenomated with a number of different snakes venoms. A monovalent antivenom is available for haemotoxic venoms. Indications for use in cytotoxic bites include swelling to the knee or elbow in 4 hours, or of the entire limb in 8 hours. With neurotoxic symptoms, or haemotoxicity with active bleeding antivenom should also be used. Therefore antivenom is indicated in this case. Antivenom shoud be administered with extreme caution as it will often cause a major hypersensitivity reaction or anaphylaxis. Therefore it is only given in a patient who is in a fully monitored bed, after intravenous hydrocortisone, chlorpheniramine and adrenaline have been administered. This regime is thought to reduce systemic hypersensitivity response to antivenom. 3. What late complications should you be vigilant for? Late complications of snake bite include haemotoxicity, which may accompany cytotoxic bites. Monitoring of INR and APTT should be carried out. Compartment syndrome secondary to tissue swelling rarely occurs and is usually related to the use of a tourniquet. Necrosis of tissue surrounding a cytotoxic bite will require debridement to prevent secondary infection.

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Learning Points  Antivenom should only be given after discussion with a Consultant experienced in the management of snake bites and in a high care facility, due to the huge potential morbidity associated with its administration.  Majority of patients do not see or cannot correctly identify the snake, hence continuous observation with regular monitoring of the level of oedema is recommended. Further Reading
Wood D, Webb C, DeMeyer J. 2009. Severe snakebites in northern KwaZulu-Natal: treatment modalities and outcomes. South African Medical Journal Vol 99 (11)

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Snake bite aftermath
The patient is admitted to the ward after a few days of observation on the resuscitation unit. After a few days the skin begins to darken and the wound and hand begins to smell offensive. A wound infection is diagnosed and broad spectrum antibiotics are commenced.

1. From the description what pathological process is occurring? 2. The patient is taken to theatre and the wound is debrided as shown. What further management do you think this patient requires?

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Snake bite aftermath

Answers

1. From the description what pathological process is occurring? Skin is very tolerant to ischaemia, hence when it starts to necrose, it is a sinister sign that the involved tissues beneath it are already dead! The snake bite – likely cytotoxic in nature, has resulted in tissue necrosis ; a brilliant culture medium resulting superimposed infection. This patient requires urgent debridement. 2. The patient is taken to theatre and the wound is debrided as shown. What further management do you think this patient requires? The flexor tendon sheath of the index finger has been involved, potentially compromising its function. The wound was extended proximally further down the dorsal forearm due to degloving of the subcutaneous tissues illustrating the extent of the bite. Loose closure of the skin proximally and application of a vacuum dressing on the hand for a few days will help to maintain relative sterility and encourage tissue granulation. There are several options for further management, which should be discussed in a multidisciplinary setting involving a Hand or Plastic Surgeon and a Hand Therapist. What happened next.. After several days of vacuum dressing, the wound was re-assessed. The index finger was amputated due to non-functioning of the flexor tendon. A split skin graft was applied with good results and the patient was discharged home with regular input from the occupational therapist.

Learning Points
   It may take several days for a snake bite injury to demarcate, hence should be monitored on the ward with anti-inflammatories and elevation. Adequate debridement to viable tissues should be performed. Further management, especially if it involves the hand, should be multi-disciplinary and led by a hand, plastics or orthopaedic specialist. Surgery is only the first step of treatment. Hand exercises should be encouraged to maintain good hand function.

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Painful left foot in a diabetic
A 56 year old female presents with a 2 week history of a mildly painful left foot. She’s not sure but believes she may have stepped on a thorn at some point in the last month. She has a background of tablet controlled type 2 diabetes and hypertension. HIV status unknown. Observations show a pulse of 125, BP of 90 / 65, temperature 38°C.

1. What is the diagnosis? 2. What definitive management would this lady require? 3. What further pre-operative information would you require about this lady in order to ensure she is optimised for theatre? 4. What important issues should this lady be counselled about before her operation?

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Painful left foot in a diabetic
1. What is the diagnosis? Wet gangrene of the forefoot.

Answers

2. What definitive management may this lady require? In a rural environment, once sepsis has become as extensive as illustrated, the most definitive option in our experience, is to perform a below knee amputation. Our experience from managing these high-risk patients with a trial of initial debridement results in on-going sepsis, morbidity and subsequent requirement for amputation, as the extent of tissue necrosis and infection is usually greater than anticipated. The degree and distribution of limb oedema may give clues as to the extent of infection in the tissues. Studies show that two stage operations for wet gangrene of the limb are the preferable option due to a brief initial operation in order to eliminate the source of sepsis, followed by further resuscitation using IV fluids and antibiotics according to local policy. Once the systemic inflammatory response has stabilised, the surgeon can plan for closure of the stump. 3. What further pre-operative information would you require about this lady in order to ensure she is optimised for theatre? Blood glucose level – in diabetics. A sliding scale is likely to be required Arterial blood gas – It is common to see a patient in ketoacidosis. Patients may be severely acidotic on presentation, and a lactate is a good marker for fluid resuscitation. FBC and Type & Screen or Crossmatch – There may be requirement for pre or intraoperative blood transfusion if the patient is anaemic. Assume the patient may lose 2 units of blood and plan appropriately. CXR and ECG for anaesthetic workup. Pre-operative anaesthetic review

4. What important issues should this lady be counselled about before her operation? Loss of a limb can be very distressing for most patients, and we have found that many will want to go home and discuss with their family before consenting. They should be informed about the possibility of two operations, further risk of wound infection and possibility for requiring a higher level of amputation (ie. Above knee (AKA)) if the stump continues to dehisce. In some patients it is relatively easy to predict whether they may need an AKA, (ie previous AKA, fixed knee contractures, sepsis extending through to proximal tibia, clinically poor vascularity) and this should be offered during the consent if there is a high chance it may be required. Presence of palpable pulses may give additional information when making this decision however it is neither a sensitive nor

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specific due to variability in detection amongst clinicians. Handheld dopplers may be useful in this situation. Post-operative physiotherapy is an important role in ensuring these patients function and mobilise well before and after discharge. Co-operation and compliance is essential as these patients can potentially lead a near-normal life with the appropriate walking adjuncts or prostheses.

Learning Points  Patients with lower limb sepsis are likely to require a brief period of optimisation in the form of fluid resuscitation and blood glucose control before definitive amputation. Broad spectrum antibiotics should be administered as early as possible.

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An odd number of gunshot wounds
A 35 year old female was unfortunate enough to be involved in gunshot crossfire near her home and sustained several gunshot injuries. She was brought into hospital 2 hours later and assessed by the resuscitation doctors. After full ATLS evaluation and initiation of resuscitation protocols, her most concerning injuries were gunshot wounds in the right upper quadrant and in the peri-umbilical region. You are called as the surgeon on call to review her. On inspection of her back, she had one further gunshot wound. Her abdomen was distended with generalised tenderness. A urinary catheter that had been inserted was draining clear urine. After 3 litres of crystalloid and 2 units of emergency blood, her observations were; pulse of 140, BP of 90/55, saturations of 95% on fiO2 of 28% and temperature of 35.7°C.

1. What are the immediate concerning issues regarding this patient? 2. How would you categorise her response to resuscitation? 3. What is the significance of having a 3 identifiable gunshot wounds? 4. If she was haemodynamically stable what further investigations could you arrange? 5. Before you take her to theatre, what other things should you arrange?

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An odd number of gunshot wounds..

Answers

1. What are the immediate concerning issues regarding this patient? She is displaying signs of grade 3 haemorrhagic shock implying a blood loss of at least 1.5 litres. Injuries sustained could be anything from solid viscus, mesenteric or vascular injuries. She needs an urgent laparotomy. She is also severely hypothermic, hence requires active warming in the form of blankets, bair huggers and warmed fluids. Hypothermia predisposes to coagulopathy which is counter-productive in a trauma patient with active haemorrhage. 2. How would you categorise her response to resuscitation? She would be categorised as a non-responder. See table below; Description After a fluid challenge of at least 2l, BP and pulse and/or CVP normalises and stays at the same level. Transient responder After a fluid challenge of at least 2l, haemodynamic observations improve to normal limits and then subsequently begin to deteriorate. Patient may either be underfilled or experiencing ongoing blood loss. Non-responder Despite fluid resuscitation, haemodynamic observations remain poor or continue to deteriorate
–

Response Stable / Responder

3. What is the significance of having 3 identifiable gunshot wounds? Clinicians become obsessed with which wound was an exit or entrance, which, in an acute setting is of minimal importance. Having an odd number of wounds implies that either one bullet is retained in the body or another exit or entrance wound has been missed. 4. If she was haemodynamically stable what further investigations could you arrange? A LODOX scan if available, is a quick imaging modality appropriate for trauma to assess for fractures and foreign bodies throughout the entirety of the body. Markers are usually placed at the site of gunshot wounds to aid determining the likely path of gunshot tracks and associated predicting injuries. A FAST scan may be used to identify the presence of free fluid, however in this scenario, a negative FAST scan will not change your management as the patient is haemodynamically unstable and enteric injuries cannot be excluded. If the patient was not haemodynamically stable, performing imaging will waste precious time spent in theatre. DSTC guidelines suggest a patient should aim to be in the emergency room for not more than 1 hour. 5. Before you take her to theatre, what other things should you arrange? This patient is likely to need high care post-operatively, so this should be arranged preoperatively if time is available.
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Learning Points  Re-evaluate the patient at regular intervals. If they are not responding to your resuscitation attempts, you need to find the source.  Do not forget to address hypothermia during resuscitation in your air-conditioned Resuscitation Unit.  Bullet wounds come in multiples of two, unless one is retained somewhere in the body.

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An odd number of gunshot wounds in theatre
The aforementioned patient is taken for a trauma laparotomy. 1. What would be your approach to the procedure? 2. Your findings include a bleeding liver wound, transverse colon and four jejunal holes in close proximity and a non-expansile central retroperitoneal haematoma. What factors would you take into consideration before you proceed? 3. You complete the operation and have decided to perform an opsite sandwich. What is that and how is it made? 4. When should the patient be taken back to theatre? 5. The ICU doctor calls you a few hours later to say the patient has had 2litres of blood drained from the abdomen opsite sandwich. She is concerned about ongoing haemorrhage. What should you do?

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An odd number of gunshot wounds in theatre
The aforementioned patient is taken for a trauma laparotomy.

Answers

1. What would be your approach to the procedure? As per DSTC and Top Knife guidelines (see Further Reading below). Enter the abdomen via a large midline laparotomy incision in no more than 3 sweeps of the blade. Pack each quadrant of the abdomen with large abdominal swabs to address the large amount of haemoperitoneum. Scoop out any obvious clots. Subsequently assess injury by systematic approach. Remove the swabs in order starting in the area where there is the least amount of blood and assess each quadrant. Inspect the bowel and its mesentery from duodenojejunal (DJ) flexure to rectum. Bladder and other pelvic structures can be inspected at this point. Stomach should be inspected anterior and posteriorly by opening the lesser sac, at which time you should inspect the pancreas. The second part of the duodenum may be visualised without mobilisation, however inspection of its entirety is difficult without performing a Kocher’s manoeuvre. 2. Your findings include a bleeding liver wound, transverse colon and four jejunal holes in close proximity and a non-expansile central retroperitoneal haematoma. What factors would you take into consideration before you proceed? The decision making process should direct you towards damage control or definitive care mode. Definitive care should be reserved for patients who are haemodynamically stable, not inotrope dependent and are requiring near normal respiratory support. In other circumstances, your main goal is to limit contamination and arrest ongoing haemorrhage. Repair of injuries can be performed at a later date once the patient has caught up on blood, fluids and the systemic insult of trauma resulting in a generalised inflammatory response. In this scenario, this patient has several injuries that need addressing, which if treated definitively, will take longer than an hour, which is the guideline for damage control trauma laparotomy. Depending on the extent of the multiple holes in the jejunum, they may be debrided and sutured if small, or tied/stapled off if large and requiring resection and anastomosis at a later date. One may attempt a deep liver suture to arrest a bleeding liver wound, otherwise it is advised to pack it. Central retroperitoneal haematomas should be explored as they are likely to be vascular injuries. If you are comfortable with repairing vascular injuries and it is actively bleeding, exploration and repair should be attempted, otherwise pack and leave until the most capable surgeon is available. 3. You complete the operation and have decided to perform an opsite sandwich. What is that and how is it made? It is a temporising measure for patients in which a definitive operation is required in the next few days. It consists of a couple abdominal swabs partially wrapped in Opsite. The swab is placed on the bowel and tucked beneath the sheath. A feeding tube is placed

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through a larger rubber drain with small holes. This is connected to suction and a further opsite is placed ontop of the skin creating a vacuum for drainage.

4. When should the patient be taken back to theatre? At the nearest convenient time once the patient has received adequate goal directed resuscitation and met endpoint requirements. 5. The ICU doctor calls you a few hours later to say the patient has had 2litres of blood drained from the abdomen opsite sandwich. She is concerned about ongoing haemorrhage. What should you do? Assess the patient carefully. Although ongoing haemorrhage is a possibility, coagulopathy and disseminated intravascular coagulation is a common cause for ongoing blood loss related to trauma. Assess how much blood has gone in and out of the patient. Have they caught up on the initial loss of fluids? Are any other sites bleeding, ie. Central lines, catheter sites and urine? What are the platelets and clotting profile? Ensure that all deficiencies are replaced at an appropriate rate remembering the need for replacing clotting factors and platelets according to your department’s massive transfusion protocol. Learning Points 1. Trauma laparotomies should be performed systematically 2. The blood bank is an important adjunct to resuscitation. Do not hurry your patient back to theatre after you have already turned off the tap as they still may be under-resuscitated. Coagulopathy is a well documented complication of SIRS secondary to trauma. Further Reading
Boffard K, Manual of Definitive Surgical Trauma Care – Second Edition (2007), Hodder Arnold Publications, Hirschberg A, Mattox K, Top Knife – The Art and Craft of Trauma Surgery (2005), tfm Publishing Ltd, UK

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Abdominal distension in a 71 year old male
A 71 year old male, referred from a peripheral hospital, presents with a week’s history of abdominal distension and absolute constipation. He denies nausea or vomiting, there is no prior history of weight loss or loss of appetite. There is no other significant medical history of note. On examination there are no signs of chronic illness. Abdomen is grossly distended and tense with hypertympanic percussive sounds. Bowel sounds are tinkling in nature. PR reveals no masses or stool. He has a pulse of 98, BP 136/72, temperature of 37.2°C and respiratory rate of 24. He is commenced on IV fluids and catheterised with a residual of 200mls dark brown urine. All blood results are within normal limits apart from a WCC of 12. Imaging was sent from his hospital as seen below.

1. What is your differential diagnosis? 2. What are the likely causes in a patient of this age group? 3. What further investigations may be appropriate in this setting to determine a definitive diagnosis?

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4. A repeat imaging was performed on the casualty LODOX scanner as there was a technical problem in the radiology department. What is the likely diagnosis and what features of this AXR is pathognomic to the condition?

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Abdominal distension in a 71 year old male

Answers

 What is your differential diagnosis? The erect AXR shows features of large bowel obstruction; grossly dilated large bowel shadows in the peripheries with a few identifiable haustrae. This patient must have a competent ileocaecal valve as there is no evidence of small bowel dilatation on this image.  What are the likely causes in a patient of this age group? Colonic malignancy Sigmoid volvulus Stricture due to diverticular disease, malignancy or chronic inflammatory process Incarcerated or strangulated hernia Ogilvie’s syndrome  What further investigations may be appropriate in a casualty setting to determine a definitive diagnosis? Repeat departmental XRay – the sacrum is not fully visualised. [adequacy of AXR] Rigid sigmoidoscopy – site of obstruction, biopsy, deflation of possibly volvulus and insertion of flatus tube Arterial blood gas  Repeat imaging was performed on the casualty LODOX scanner as there was a technical problem in the radiology department. What is the likely diagnosis and what features of this Xray is pathognomic to the condition? Sigmoid Volvulus Coffee bean sign, originating from the left iliac fossa Learning Points  Large redundant sigmoid colons with narrow based mesenteries are a recipe for volvulus and are relatively common in Zululand.  Patients with a complete volvulus may not appear to be very sick as the ischaemic metabolites are isolated from systemic blood flow in the volved segment. Be aware that they may deteriorate significantly intraoperatively and require a high care facility postoperatively.

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Patient involved in tractor trauma
A man of unknown age is involved in a MVA where he fell off a tractor and dragged along for a short period of time. He suffers multiple ‘road rash’ abrasions to his body. ATLS assessment reveals a small scalp haematoma, two right posterior rib fractures and a right open tib/fib fracture. Abdomen is mildly distended and tender. His pulse is 140, BP 87/64 with a respiratory rate of 34.

1. What are the indications for peforming an eFAST scan? 2. Which eFAST view is this and what does it show?

3. Approximately how much free fluid is required to be present in the abdomen in order for it to be reliably detected? 4. How sensitive is the FAST scan for determining need for laparotomy in penetrating compared to blunt trauma? 5. This patient stabilises to a pulse of 110 and BP of 120/70 after resuscitation with crystalloid and blood transfusions. What is your next management plan?

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Patient involved in tractor trauma
 1. 2. 3. 4. 5.

Answers

What are the indications for peforming an FAST scan? For haemodynamically unstable patients where the cause is undetermined Patients requiring transfer from a rural /district hospital with polytrauma Intoxicated trauma patients who require re-examination Patients with multiple wounds, penetrating trauma or unclear trajectory Any patient with whom there is concern

 Which FAST view is this and what does it show? This view demonstrates Morrison’s pouch which is the right upper abdominal view between the liver and the kidney most easily viewed between the 8th and the 11th intercostal space. The fluid visible (black area) between the liver and the kidney indicates a positive FAST scan.  Approximately how much free fluid is required to be present in the abdomen in order for it to be reliably detected? Identification of free fluid is operator dependent, however with good views approximately as little as 200mls can be identified.  How sensitive is the FAST scan for determining need for laparotomy in penetrating compared to blunt trauma? FAST scans can determine the presence of haemoperitoneum after significant blunt abdominal trauma. The cause is usually due to a solid organ injury, most commonly the spleen or liver. This investigation can be reliably repeated and can lead the clinician to determine whether a CT or laparotomy would be indicated. There is limited use and sensitivity of a FAST scan for penetrating injuries in determining the need for laparotomy as bowel injuries may not result in visible free fluid on ultrasound.  This patient stabilises to a pulse of 110 and BP of 120/70 after resuscitation with crystalloid and blood transfusions. What is your next management plan? Once stabilised the patient’s open fracture should be washed out and reduced if possible in the emergency unit, then redressed. He then warrants a full body CT with oral, IV and if indicated, bladder contrast to determine the extent of the injuries. If no other significant injuries are noted, Orthopaedic intervention should be sought and the patient should be monitored in a high care or specialist trauma unit. Learning Points  FAST scan is quick, easily reproducible and non-invasive method to identify free fluid in the abdomen in a trauma patient, however it is non-specific and operator dependent. Further Reading
Reardon R, Focused Assessment with Sonography in Trauma http://www.sonoguide.com/FAST.html Accessed December 2011

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Another stab chest
A 34 year old male is stabbed in the left side of the chest whilst walking home one evening. He attends his local casualty department. He is haemodynamically stable. His wound appears to be in the mid axillary line, 6th intercostal space. Good breath sounds are auscultated bilaterally. Abdomen is generally soft with mild left upper quadrant tenderness. An erect CXR is organised which appears to be normal. 1. What are your possible concerns about this patient? 2. Blood results are normal. Would you discharge the patient from casualty? 3. The casualty senior states she is concerned that he may have sustained a penetrating diaphragmatic injury. How could you investigate this?

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Another stab chest

Answers

1. What are your possible concerns about this patient? Unless an accurate description of the weapon and depth of penetration is available, it is difficult to ascertain the distance of possible penetration and in which direction. Here is where surface anatomy is extremely useful! In this case the patient may have sustained a lung parenchymal, pleural or intra-abdominal injury. 2. Blood results are normal. Would you discharge the patient from casualty? Despite normal blood results it is wise to have a high suspicion for concomitant injuries, hence admitting for observation or for arranging further imaging is advised if the patient is co-operative. Alternatively the patient can be discharged with advice that if any further pain develops, he should return immediately. The consequences of penetrating injury may not be apparent early on. 3. The casualty senior states she is concerned that he may have sustained a penetrating. diaphragmatic injury. How could you investigate this? Gold standard method of investigation would be a diagnostic laparoscopy or thoracoscopy, which is less invasive than laparotomy or thoracotomy. It is very difficult to identify small penetrating injuries of the diaphragm using conventional modes of imaging (CT, U/S, MRI).

Patient with multiple leg lacerations post MVA
A 45 year old female was sent from a peripheral hospital having been involved as a passenger in a taxi which rolled down a hill. There were several casualties, but no deaths. She is a fairly obese lady. On examination, her airway is patent and chest is clear. Pulse is 80 and BP 145/85. She appears to have a small hole – possibly the result of a penetrating injury low in her right flank in the mid axillary line, where fat is extruding. She is locally tender over the wound, however the rest of the abdomen is soft. Her legs contain multiple abrasions, significantly a right knee abrasion exposing fat and possibly part of the patella bone and two left anterior thigh lacerations exposing fat. No bony injury could be identified. She was taken to theatre to debride and clean the wounds. The thigh laceration was explored, resulting in the following picture.

1. What type of injury does this picture illustrate? 2. What is the pathophysiology of this type of injury? 3. What general management options are available to you? 4. Where should this patient be managed post-operatively?

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5. The abdominal injury was explored and found to be entering the retroperitoneum. Which hollow viscus organs in the abdomen are particularly susceptible to shearing forces?

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Patient with multiple thigh lacerations post MVA
 What type of injury does this picture illustrate? Massive circumferential degloving injury of the left thigh.  What is the pathophysiology of this type of injury? Shearing forces disrupt the skin and subcutaneous fat from underlying layers of tissue, in many cases, eliminating its blood supply. This leaves an area of dead space which is prone to fluid collections and subsequent infections.  What general management options are available to you? Initial operation should be directed at exploring the wound to the full extent of the degloving and cleansing the area of contaminants sustained in the MVA. If skin viability is dubious, the skin can be apposed, and the leg wrapped in bandaging to be reviewed a few days later. She should be placed on prophylactic antibiotics. Split or full thickness skin grafts may be required to achieve full coverage of the injury. Seek Plastic Surgery advice for these kind of injuries.  Where should this patient be managed post-operatively? This patient should be managed in a high care unit. This massive injury is associated with a large amount of insensible fluid losses and high risk of sepsis.  The abdominal injury was explored and found to be entering the retroperitoneum. Which hollow viscus organs in the abdomen are particularly susceptible to shearing forces? Shearing forces can occur anywhere where part of the organ is at a fixed point. The duodenal-jejunal (DJ) flexure is particularly susceptible to this. Other areas include the ileocaecal junction, small bowel mesentery and rarely the rectum at the junction of the intra to retroperitoneal part.

Learning Points  Always take into account the mechanism of injury when evaluating a patient. A relatively innocuous wound can lead to devastation if a degloving injury is missed.

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Patient in a hot situation
A 7 year old male sustained a hot water burn as seen below. His mother stated that he managed to pull down a kettle pouring the water over himself about 4 hours ago. He had no significant past medical history. His observations were within normal limits. Examination of the chest was clear. His weight was noted to be 22 kg

1. What should your primary management of this patient be? 2. Approximately what is the percentage and likely depth of the burn?

3. Do you know of any formulas to calculate the fluid requirement of this patient?

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4. What dressings are these shown below? What are the benefits of their use?

5. What further management issues should you consider for this patient?

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Patient in a hot situation
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Answers

What should your primary management of this patient be? According to ATLS principles;  Identify life threatening injuries  Ensure no signs of inhalation injury (commonly associated with flame burns) o Face or neck burns o Singeing of the eyebrows and nasal vibrissae o Carbon deposits and acute inflammatory changes in the oropharynx o Carbonaceous sputum o Hoarseness o History of impaired mentation and or confinement in a burning environment o Explosion with burns to head and torso o Carboxyhemoglobin level greater than 10 % in patient who was involved in a fire  Stop the burning process o Cover burned surface with water if time of injury <2hrs o Cover with an occlusive dressing (cling wrap) to prevent evaporation and cooling o Maintain core temp around 37 degrees o Use of a burnshield for cooling, if available  Iv access and IV fluids  Bloods: o full blood count and haematocrit o U&Es, T&S and/or Cross Match , LFT (albumin) What is the approximate percentage and likely depth of the burn? The calculation of burns should be as per percentage total body surface area (%TBSA) involvement according to diagrams for a child over the weight of 10kg (see appendix). The approximate percentage for this patient would be 15%. Wallace rules of 9 are used for adults. Burns depth as described are likely to be partial thickness identifiable by blanching on palpation. View the appendix for more information on determining burn depth. The depth can be variable throughout. Do you know of any formulas to calculate the fluid requirement of this patient? How much would you give this boy? Parklands formula is used to calculate the fluid requirements in a patient as follows; 4 x %TBSA x weight (kg) = total mls

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First half should be given within the first 8 hours of the burn, the rest given in the next 16 hours. This patient requires; 4 x 15 x 22 = 1320ml Therefore he should be given 660ml within 8 hours of the burn. It is now 4 hours since the burn so he should be given 330ml stat followed by the next 330ml in the next 4 hours. The final 660ml should be given at a continuous rate within the next 16 hours. View the appendix for calculation guidance. We use ringers lactate for resuscitation, which is isotonic, and has a relatively lower sodium content compared to normal saline. Other options include 5% dextrose with 0.45% Saline (if used, monitor HGT regularly) for maintenance in children, and plasmolyte solutions. What dressings are these shown below? What are the benefits of their use? Acticoat is silver impregnated polyethelene mesh with antimicrobial barrier properties. It can be used for 2-3 days on partial, full thickness and recently debrided open wounds. It is also suitable for donor and graft sites. Jelonet is a cotton weave impregnated with white paraffin, used to apply directly to open wounds, which is then covered by another dressing type (ie. gauze). It has no antimicrobial properties. What further management issues should you consider for this patient? In our practice, any patient with a total body surface area burn of 12% or more, should be admitted to high care for further monitoring and fluid resuscitation. These patients are at high risk of several morbidities including hypovolaemic shock, hypothermia, anaemia, malnutrition and sepsis. All patients are provided with an NG feeding tube to encourage enteral feeding as early as possible. A urinary catheter is inserted to monitor fluid output and to give indication of optimal resuscitation. Learning Points  Every hospital should have a goal directed burns management protocol in order to ensure patients with significant burn injuries are managed appropriately. This should be a multidisciplinary approach.  See Appendix for further burns sheet

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A community assault
A 22 year old man is brought to casualty by the police twenty four hours after he was beaten by his community. They used sjamboks (heavy whips) to beat him and he reports that he fell to the ground. He now complains of pains throughout his body, worst in his right arm and over his back. He is walking normally and reports that he did not lose consciousness during the attack. HR is 95, BP 120/75, RR 18. Examination reveals widespread bruising with ‘tram lines’ on his back and decreased range of movement and diffuse swelling over his right forearm. He also has an undisplaced ulnar fracture which is managed in a back slab and orthopaedic opinion sought. The nursing staff perform a urine dipstick which shows 4+ blood with a pH of 6. 1. What is the underlying diagnosis and what single laboratory test can you request, which will confirm this? 1. What is the appropriate treatment? 2. His blood results: Hb 13.5 WCC 8 Plt 436 Cr 195 Urea 13 Na 135 K 5.1 LFTs Normal Amy 120 CK 10,650

What is the major complication of this condition, and how would you best manage it?

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A community assault
1. What is the underlying diagnosis and single laboratory test can you request which will confirm this? Crush syndrome is caused by the breakdown of muscle and soft tissues with release of creatinine kinase (CK) and other muscle proteins. This is evidenced by myoglobinuria and injuries consistent with crush syndrome (widespread bruising, entrapment, circumferential burns). It can be confirmed by testing for serum CK levels, where levels greater than 5000 are pathognomic. This patient has also suffered a classical ‘defence fracture’ of the right forearm. 2. What is the appropriate treatment? Treatment must be initiated early, with the aim of establishing a diuresis, which allows renal excretion of the excess serum proteins and prevents blockage of the renal glomeruli. 0.9% NaCl is started at 500mls/hour, and a urinary catheter placed to measure urine output. If urine output is poor after 3 to 4 litres of intravenous fluid, mannitol may be trialled, and if oliguria persists then furosemide boluses become necessary. Bicarbonate can also be used to alkalinise the pH of urine, which allows excretion of higher concentrations of muscle proteins. Treatment is successful when urine is normal with no myoglobinuria and renal function is normalised. 3. What is the major complication of this condition and how would you best manage it? Renal failure is the main complication of crush syndrome which is identified by poor urine output despite adequate fluid therapy and use of diuretics. Adjuncts to diagnosis include CVP, serum urea and creatinine, the presence of peripheral oedema and raised jugular venous pressure, and finally evidence of pulmonary oedema. If this occurs the only recourse is to dialysis, which is usually effective in improving renal function. Early aggressive fluid therapy is paramount in the treatment of crush syndrome, because delayed presentation or inadequate fluid resuscitation makes renal failure more likely. Defence fractures are commonly missed in crush syndrome, and other injuries related to the initial trauma should be carefully sought out and managed. Learning Points  Crush syndrome is under-diagnosed, hence have a low threshold of suspicion in patients suffering from assault, blunt trauma or history of prolonged immobility.  Monitoring microscopic haematuria on urine dipstick for crush syndrome is not sensitive, especially in a population where there are several common pre-morbid causes ie, bilharzia, diabetes, hypertension etc.

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Tractor traction
A 11 year old male fell under a tractor and was dragged along the ground for a short period. On admission to the resuscitation unit he was assessed as follows; A – patent. Talking in sentences B – Decreased air entry bilaterally. Saturations 79% on air. RR 30 C – pulse 130 BP: 105/90 cool peripheries D – GCS 15/15 1. What would your primary management be? 2. The patient is stabilised by the casualty team. His abdomen is generally tender. What would your next step be?
3. What are your management options?

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Tractor traction

Answers

1. What would your primary management be? Your treatment should be according to ATLS protocol. Cervical spine should always be assessed and should not be cleared if a patient is in collar and blocks until adequate imaging has been arranged and/or a C-spine injury has been clinically excluded by an experienced health professional. He is noteably hypoxic with evidence of haemorrhage which will require O2 delivery and likely crossmatch for blood transfusion. He also requires a urinary catheter, and a formal logroll with assessment of PR tone. 2. The patient is stabilised by yourself and the trauma team. His abdomen is generally tender. What would your next step be? The patient requires trauma series Xrays – CXR, Pelvis, Lateral, AP and open mouth cervical spine. If an abdominal injury is suspsected, there are several options available to diagnose a significant intra-abdominal injury in a trauma setting: Procedure FAST Pros Cheap and quick Easily accessible Reproducible No radiation dose High sensitivity and specificity Reproducible Cons Operator dependent Not quantitative – either positive or negative Not diagnostic for type of free fluid or injury sustained Named ‘donut of death’ for a reason Dependent on accessibility Expensive Radiation dose to patient Invasive Time consuming (awaiting results) Not diagnostic to injury sustained if haemoperitoneum Operator dependent Not always easily accessible in a trauma environment

Computerised Topography

Diagnostic Peritoneal Lavage

Diagnostic to presence and type of free fluid

Ultrasound

Cheap and quick Reproducible No radiation dose

3. What are your management options? Children who are relatively stable with intra-abdominal solid organ injuries identified on CT, should be managed conservatively and actively monitored in a high care facility. Indication for laparotomy includes non or transient response to resuscitation, requirement for massive transfusion and evidence of ongoing concealed haemorrhage, evidence of significant abdominal compartment syndrome.

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Learning Points b. Up to 95% of children with blunt abdominal trauma can be managed conservatively in appropriate trauma centres, however it is important to acknowledge that the abdomen is the most common site for unrecognised fatal injuries in children who have suffered trauma. c. Familiarise yourself with the normal vital signs and fluid resuscitation protocols for children. They tend to have a considerably good cardiovascular reserve, hence may not display obvious signs of shock until they are peri-arrest. d. Transfer of a paediatric trauma patient to a specialist paediatric trauma centre, if available, is highly recommended. Further Reading
Saxena A (2011). Paediatric Abdominal Trauma. http://emedicine.medscape.com/article/1984811-overview Accessed December 2011 Alterman D (2011) Considerations in Paediatric Trauma http://emedicine.medscape.com/article/435031overview#a1 Accessed December 2011

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Gunshot injury to the thigh
A man was shot in the right anteromedial thigh region and then presented 4 hours later to casualty. After resuscitation it was noted that his right lower limb was cold and had no peripheral pulses. He had reduced sensation and 2/5 power.

1. What factors into your checklist for the preparation of a vascular injury exploration? 2. What does the following picture show? What are the landmarks for this?

3. Why is it performed? 4. A vascular injury to the femoral artery is repaired and the patient progresses well on the ward with an increasingly warm and mobile foot! What are your options for closure of this wound?

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Gunshot injury to the thigh

Answers

1. What factors into your checklist for the preparation of a vascular injury exploration? FBC, U&Es, Crossmatch 2 units on standby. Consent form – also for the possibility of requiring saphenous vein harvesting for grafting and amputation of the limb if the leg is not viable 2. What does the following picture show? What are the landmarks for this? This is an example of lower limb fasciotomies. On the lateral side an incision is made anterolaterally approximately 2 cms anterior to the fibular shaft, and should be of adequate length to open up the lateral and anterior compartments. Care should be taken not to damage the common peroneal nerve which winds around the neck of the fibula. The medial incision opens the superficial and deep compartments with a single longtitudinal incision posterior to the posteromedial border of the tibia. The soleus should be detached from the posterior tibia in order to open up the deep compartment. The fascia is incised allowing decompression of the 4 leg compartments and inspection of the muscle. Diathermy may be used to stimulate the muscle fibres to determine the presence of contraction. 3. Why is it performed? Primarily to assess limb viability if there is any doubt. If deemed viable, one can proceed to a vascular exploration and repair. Revascularisation of an acutely ischaemic limb can have several problematic sequelae including oedema, crush syndrome resulting in renal failure and failure to revascularise resulting in ongoing ischaemia and necrosis. Fasciotomies allow for direct inspection and monitoring of the limb (remember skin changes in ischaemia occur much later than that of other tissues) and compartmental release protective against the development of compartment syndrome in swelling. 4. A vascular injury to the femoral artery is repaired and the patient progresses well on the ward with an increasingly warm and mobile foot! What are your options for closure of this wound? o Primary closure. Usually possible on one side and very difficult on the other. o Skin grafting for areas which cannot be closed by suturing due to tension o Secondary closure – allow the wound to granulate. Grafting however would be preferable to protect against wound infections and fluid losses. Learning Points 1. Always consider a fasciotomy before you commence your lower limb vascular exploration and repair

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A directed kick
A 35 year old male was kicked in the suprapubic region by a foe. He subsequently was unable to urinate and began to complain of abdominal pain. On admission to casualty, observations were within normal limits. Abdomen was generally quite tender with no signs of peritonism. A catheter was introduced with some difficulty, revealing an output of frank haematuria which subsequently began to clear to a rosé colour. 1. What methods could you use to diagnose a bladder injury? 2. What is this investigation? What are the limitations of the first image?

3. What do these images show? 4. How would you manage this patient?

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A directed kick
1. What methods could you use to diagnose a bladder injury? Cystogram CT cystogram – useful if other intra-abdominal injuries suspected. 2. What is this investigation? What are the limitations of the first image? This is a cystogram; performed by inserting 250mls of urograffin via the urinary catheter into the bladder. The catheter was clamped and an erect AXR was taken. The catheter clamp was subsequently released and a post void film was taken. Limitations include the clamp is obscuring part of the image and the radiograph is focused only on the pelvis rather than the entire abdomen. 3. What does it show? The retention film shows a flame shaped bladder with contrast apparent between bowel loops. The post void film shows some contrast remaining in the bladder, however contrast is visible throughout the abdomen. This film shows an intraperitoneal bladder rupture. 4. Can this patient be managed conservatively? Intraperitoneal bladder rupture requires a laparotomy and repair of the bladder injury. Urine within in the peritoneum acts as an irritant and eventually leads to secondary peritonitis. Visualisation of intact vesico-ureteric junctions need to be documented. The bladder is closed in two layers using an absorbable suture. A urinary catheter is left in the bladder to allow time for healing of the injury under low pressure. A cystourethrogram should be performed before the catheter is removed to ensure there are no further leaks. This can be done after about 2 weeks of continuous drainage. Learning Points  A cystogram can easily and quickly be performed in a casualty setting to diagnose bladder injuries.  Intraperitoneal bladder injuries require a formal laparotomy and repair.

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Managing a kidnapped patient
A 22 year old female was kidnapped and found 16 hours later in a field unconscious. She is brought in by paramedics in the resuscitation bay. Your assessment is as follows: A with C-spine control – not talking. Breathing spontaneously. B – RR 30 sats 80% on air, dull percussion and decreased air entry bibasally C – pulse 140 BP: 67/40 cap refill >3 seconds . cool peripheries D – GCS E1 M5 V2 HGT – 5 temperature 35 degrees Celsius. Pupils equal and reactive to light. She has 4 stab wounds on the right side of her neck in Zone 1 and 2. One wound in Zone 1 has an associated haematoma. Abdomen is soft and mildly distended. She also appears to have been raped. 1. What interventions would you perform for A, B, C and D?

2. What are the possible sources of haemorrhage?

3. What important structures are at risk in a Zone 1 neck injury?

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4. a. What investigation is this? b. What are the labelled structures? c. What injury can be seen?

5. Considering this patient has been raped. What other investigations and treatment should be instigated?

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Managing a kidnapped patient
1. What interventions would you perform for; A with C spine – remain immobilised until C spine injury excluded. Ensure mouth is clear with attempted suctioning. Keep airway maintained using adjuncts if tolerated B – administer 100% O2 via non-rebreathe mask. C – This patient has suffered a grade 4 haemorrhage. Insert 2 peripheral wide bore. Take bloods for Cross match, FBC, U&Es. Give a fluid challenge of 2l with crystalloid or colloid if available. Patient is likely to have had significant blood loss, so starting a blood transfusion early by using emergency blood until cross match is available, is essential. Dependent on your massive transfusion protocol, you should also consider fresh frozen plasma and platelets for transfusion. D GCS – 7 hence her ability to maintain her own airway is compromised. If her saturations do not improve with simple measures as prescribed above, and a tension pneumothorax has been excluded, intubation should be considered. Her low GCS could be attributed to a variety of potential pathologies, however the most pressing issues are hypoxia and haemorrhage, which should be addressed first. CT head should be considered only after the patient has been stabilised. It is extremely important to normalise her temperature as she is at high risk of becoming coagulopathic, hence bair huggers and warming blankets should be introduced. 2. What are the possible sources of haemorrhage? Brain, Neck, Chest, Abdomen 3. What important structures are at risk in a Zone 1 neck injury? Common carotid, internal jugular vein, subclavian artery, innominate vein, trachea, oesophagus, lung apex 4. a. What investigation is this? Axial CT angiogram of the neck b. What are the labelled structures? A – right internal jugular vein, B – right common carotid artery, C – trachea D – cervical vertebral body

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c. What injury can be seen? The right internal jugular vein (IJV) appears to have a filling defect. This may represent a thrombus at the site of injury. There is also some evidence of air in the soft tissues local to this.

5. Considering this patient has been raped, what other investigations and treatment should be instigated? Rape kits for victims should be available in your hospital and should be performed by a health professional trained in conducting the procedure. A variety of swabs are taken from the victim’s body including other evidence such as clothes. Post-exposure prophylaxis for HIV should be available for the patient as soon as the event occurs with subsequent HIV testing of the patient Learning Points  CT angiograms can be used to diagnosed vascular injuries of the neck. IJV injuries, if they are no longer actively bleeding, can be managed conservatively, however should be observed for a period of time.  Concealed haemorrhage in the trauma patient can occur in several body cavities, hence a formal ATLS assessment to identify potential sites. In the stable and/or unconscious trauma patient, a ‘full body CT’ may be arranged. Further Reading
Inaba K et al. 2006 The nonoperative management of penetrating internal jugular vein injury. J Vasc Surg. Jan;43(1):77-80. Information of Rape Kits. DNA Project SA. http://dnaproject.co.za/crime-scenes/rape Accessed December 2011

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Neck Exploration
The concerning Zone 1 neck wound was found not to be actively bleeding and sutured up in casualty. She was intubated after it was diagnosed she had also developed a pneumonia and continued ventilation in intensive care. A few days later she suffered spontaneous bleeding at that site which was controlled by pressure by the one of the ICU nurses. She was subsequently taken to OT for an exploration. 1. What incision should be made? 2. What strategy should be adopted in order to find the IJV and control the bleeding? 3. There is a lateral injury of the IJV and the external jugular vein. What are your options? 4. If the external carotid artery was severely injured, would this be safe to ligate if repair was not possible?

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Neck Exploration

Answers

The concerning Zone 1 neck wound was found not to be actively bleeding and sutured up in casualty. She was intubated after it was diagnosed she had also developed a pneumonia and continued ventilation in intensive care. A few days later she suffered spontaneous bleeding at that site which was controlled by pressure by the one of the ICU nurses. She was subsequently taken to OT for an exploration. 1. What incision should be made? An incision should be made along the anterior border of the sternal head of the sternocleidomastoid (SCM) from the jugulosternal notch to the mastoid. Dissection through the platysma and lateral retraction of the SCM should open up the path to the IJV. 2. What strategy should be adopted in order to find the IJV and control the bleeding? Dissection through the platysma and lateral retraction of the SCM should open up the path to the IJV. Try to avoid entering the haematoma itself as the anatomy will have become distorted and it will be extremely easy to get lost. The key is finding the normal anatomy and gaining distal and proximal control. 3. There is a lateral injury of the IJV and the external jugular vein (EJV). What are your options? Both veins can be safely ligated. Attempt at repair of the IJV should only be sought if the patient is haemodynamically stable, and the surgeon is confident in his technical skills. 4. If the external carotid artery was severely injured, would this be safe to ligate if repair was not possible? The external carotid artery provides blood supply to the face and has plentiful anastomoses between the both sides, hence ligation would be reasonable without significant consequences. What happened… This patient was not actively bleeding in the resuscitation unit hence the decision was made not to explore the injury, however she was intubated due to a low GCS and respiratory problems thought secondary to shock and a lower respiratory tract infection. Whilst being monitored in ICU, she started spontaneously bleeding from the wound whilst being washed by a nurse, hence was rushed straight to theatre. A complete external jugular and lateral internal jugular vein was identified. The IJV injury was very close to the clavicle, and due to difficulties controlling the bleeding, it was eventually ligated. She was sent back to ICU, however subsequently died of multi-organ failure. She never regained consciousness despite stopping sedation, which was thought to be due to hypoxic brain injury secondary to prolonged shock after the initial assault.

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Patients in a house fire
A ten year old was brought from a house fire presenting with a candle wax burn to his abdomen comprising 6 % TBSA. He had no significant past medical history and otherwise clinically well but crying. All observations were normal. His wound was covered with candle wax.

1. What are your general concerns with the type of burn sustained?

2. Having assessed the burn the dermis appears have a leathery appearance. On palpation the child appears to be in no pain. What type of burn is this and what further management may you consider?

3. Does this patient meet any of the admission criteria for burns patients?

4. The patient’s mother who was also involved in the house fire was brought into hospital. She has sustained 80% flame burns to her body with facial involvement. Her observations are as follows; pulse 140, BP 85 / 60, temperature – 35 degrees, GCS of 8. What general management options are available for her

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Patients in a house fire

Answers

1. What are your general concerns with the type of burn sustained? Despite the patient appearing clinically well, his airway should be regularly assessed and monitored as an inpatient due to concerns regarding inhalational injuries which may potentially require intubation due to upper airway oedema and/or irritation from carbon deposits. Have a high suspicion of 3rd degree / full thickness burns in any patient that has been exposed to flame or hot candle wax injuries. The candle wax should be removed to assess the wound and to remove a potential source of ongoing heat. 2. Having assessed the burn the dermis appears have a leathery appearance. On palpation the child appears to be in no pain. What type of burn is this and what further management may you consider? This patient has sustained a full thickness burn. He will require debridement under general anaesthesia until healthy bleeding tissue is exposed. Subsequent skin grafting should be performed to cover this area, reduce the risk of localised sepsis and to encourage wound healing. If this burn was circumferential, an escharotomy should be considered. 3. Does this patient meet any of the admission criteria for burns patients? The admission criteria specific to this patient’s management includes the following  Full thickness burns of greater than 5% TBSA in any age group.  Risk of inhalational injury These are only guidelines, and should be managed based on individual patient factors. 4. The patient’s mother who was also involved in the house fire was brought into hospital. She has sustained 80% flame burns to her body with facial involvement. Her observations are as follows; pulse 140, BP 85 / 60, temperature – 35 degrees, GCS of 8. What is her general probability of outcome? Patients with severe burn injuries of a high %TBSA in our experience have a very low survival rate. The Baux score may be used to predict probability of death (age + %TBSA) which can also be combined with evidence of inhalational injury using the revised method (+ 17), but there have been no studies to determine whether this can be extrapolated to the general Zululand population where TB, HIV and other significant comorbidities are endemic. Patients should be discussed as early as possible with the nearest specialist burns or trauma unit. Initial treatment should still follow ATLS principles until a definitive decision has been made. Learning Points  Even candle wax can be an ongoing source of burn, hence it is imperative to remove it and assess the underlying damage to the skin beneath it.  Debride burns until it reaches healthy bleeding tissue. These patients should be Cross matched in preparation for this procedure as they can potentially lose a lot of blood. Adrenaline soaked gauze (1mg in 500mls normal saline) or Burns solution ; a
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Another patient with abdominal distension
A 37 year old male presented to casualty with 3 days of abdominal distension and nausea. He had opened his bowels small amounts. He had a background of HIV with a CD4 count of 120 and taking ARVs. He had been diagnosed with pulmonary TB 3 months ago and had started taking treatment. On examination he appeared mildly dehydrated with a pulse of 110, BP of 100/69, saturations of 94% on air. His abdomen was distended and generally tender with hypertympanic percussion notes and tinkling bowel sounds. 1. What would your primary management plan be aimed at? 2. What is this image and what does it show?

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3. Another investigation was organized, what is it and what does it show? The image is of a different patient.

4. The patient’s symptoms settle after resuscitation and he is transferred to the ward. What further investigation could you organize to investigate the possible aetiology to his symptoms? 5. The patient was diagnosed with TB abdomen. What are the possible reasons for developing these symptoms? 6. The patient is subsequently discharged from hospital. What further advice would you give him with regards to his TB treatment?

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Another patient with abdominal distension

Answers

1. What would your primary management plan be aimed at? Fluid resuscitation of the patient and decompression using a nasogastric tube. 2. What is this image and what does it show? This is an erect AXR with multiple air fluid levels indicating several fluid filled loops of bowel which you may see in small bowel obstruction. There is barely any identifiable gas in he colon on this image as it is collapsed. 3. Another investigation was organized, what is it and what does it show? This is a Gastrografin Follow Through with dilated small bowel loops (>3cm diameter) and contrast in the stomach, duodenum and some of the small bowel. Initially the patient ingests 80ml of gastrografin and subsequent films are taken at 2, 4 and 6 hours to determine whether the contrast reaches the caecum. In the normal bowel, transit of gastrografin to the caecum should take 2-4 hours. Depending on surgeon’s preference, if contrast does not reach the caecum within a reasonable time period (sometimes up to 24 hours), surgical intervention may be required. Gastrografin is a hyperosmolar substance with possible therapeutic properties; a study has found it significantly reduces the need for surgery in patients with bowel obstruction after conservative treatment has failed 1. 4. The patient’s symptoms settle after resuscitation and he is transferred to the ward. What further investigation could you organize to investigate the possible aetiology to his symptoms? CT abdomen with IV and oral contrast will assist in determining the site and cause of obstruction. 5. The patient was diagnosed with TB abdomen. What are the possible reasons for developing these symptoms? TB abdomen can cause mechanical and functional bowel obstruction, and may result in localised intestinal perforations, which are usually associated with poor outcomes. TB treatment may result in bowel scarring and strictures once the lesions begin to resolve which may lead to a presentation of bowel obstruction. The terminal ileum is a commonly affected region. 6. The patient is subsequently discharged from hospital. What further advice would you give him with regards to his TB treatment? This patient is likely to require an extended period of TB treatment as he has extrapulmonary disease. This is likely to be from 9 – 12 months in total. Follow-up should be organized at his local TB clinic.

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Learning Points
  TB abdomen may present acute or chronically, mimicking most gastrointestinal diseases. Have a high suspicion is patients with a previous or current history of TB. Medical treatment is the key to treatment. Surgical intervention should be reserved for patients who are likely to survive surgery and where conservative treatment has failed.

A patient with head trauma
A 34 year old man was struck across the head by an unknown assailant with a blunt object 4 hours ago. He subsequently was able to go home, but a few hours later started to develop a severe headache and vomiting. He was brought in by his sister who was fairly concerned that he wasn’t ‘himself’. He was brought into casualty and was reviewed by the one of the doctors. Examination findings; A – patent B – equal air entry bilaterally. Vesicular sounds. RR 25 Sats 98% on air C – pulse 87 BP 130/79 warm peripheries D – GCS E4 M6 V4 BM – 5.9 Pupils equal and reactive to light Temperature – 37.2 degrees centigrade

The casualty doctor calls you for advice. 1. What features of the history are concerning? 2. What further investigations would you request? 3. Where should this patient be managed whilst waiting for results? 4. What is the following image and what does it show?

5. What is the cause of this type of injury? 6. What is your treatment plan?

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A patient with head trauma

Answers

1. What features of the history are concerning? Despite the lucid period, the patient has started to develop signs of meningeal or dural irritation; severe unremitting headache, vomiting and fluctuating GCS. 2. What further investigations would you request? A basic set of bloods including a FBC, U&Es and also a clotting screen The patient will also need an urgent CT head organized to exclude a significant head injury. 3. Where should this patient be managed whilst waiting for results? The patient should be monitored in a resuscitation unit or area which is exposed where there will be a nominated health professional to perform and document neuro observations at regular intervals. 4. What is the following image and what does it show? This is an axial slice of a plain CT head. The image illustrates a large left sided extradural haematoma. The diagnostic features include a well defined concavity where the dura is being compressed externally. There is also evidence of midline shift and partial compression of the left ventricle with some blood in the midline sulcus. 5. What is the cause of this type of injury? This type of injury is usually caused by direct trauma to the middle meningeal artery which runs behind the pterion which marks the junction between the parietal, greater wing of the sphenoid, frontal and temporal bone. This area is particularly thin, hence forces are transmitted to the artery, which ruptures and causes an extradural haematoma. 6. What is your treatment plan? This patient will require an urgent decompressive craniotomy and evacuation of the haematoma. You should discuss this patient with the neurosurgical doctors at the earliest opportunity, as a continually expanding haematoma will lead to the patient coning resulting in brain stem death. A drop in GCS below 8 will likely require the patient to be intubated in order to protect their airway, hence any transport plans should include appropriate personnel with airway skills. Learning Points  Familiarise yourself with the clinical indications for performing a CT head in adults and children. If in any doubt, discuss with your senior or neurosurgical doctor. (see appendix)  If a CT is not required, or the patient’s CT was normal and clinically well, they should be monitored for 24-48 hours post injury by a responsible adult and given a head injury advice card. Not all patients need to be admitted into hospital.

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An odd gunshot neck
A 29 year old male walked into casualty stating that he had sustained a gunshot injury to the neck several hours earlier. He otherwise felt well. On examination he was talking normally with no respiratory distress or audible stridor. An entrance wound left of the midline as shown, was observed. Chest was clear and abdomen was soft and non-tender. All observations were within normal limits.

1. How would you primarily manage this patient? 2. Which zone is the injury in? 3. What would be your concerns about this injury and what imaging would request?

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4. The location of the bullet could not be found on skull, neck or chest XR, hence further imaging was organized. What does this image show and where is the likely location of the bullet considering his abdominal examination was normal?

5. What would be your management plan for this patient?

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An odd gunshot neck

Answers

1. How would you primarily manage this patient? All trauma patients require primary survey evaluation as per ATLS protocol 2. Which zone is the injury in? This injury is at the border of Zone 1 and 2, therefore a high suspicion of injury for all structures in those areas should be maintained. 3. What would be your concerns about this injury and what initial imaging should you request? Despite the patient appearing clinically well, he may have sustained injuries that may not be clinically apparent at an early stage. There is also only one bullet wound, hence the bullet must still be retained in the body. Its location must be determined. Trauma series (CXR, C-spine lat and AP and Pelvis X-Rays) should be performed initially if a LODOX scanner is unavailable. Ultrasound Doppler of the neck if trained personnel are available, can be useful to identify Zone 2 vascular injuries. A gastrograffin swallow should be performed to exclude oesophageal injury, hence the patient should remain nil by mouth. CT angiogram of the neck and chest if available using oral contrast will be of diagnostic value for occult injuries. 4. The location of the bullet could not be found on skull, neck or chest XR, hence further imaging was organized. What does this image show and where is the likely location of the bullet considering his abdominal examination was normal? This is an AXR that was taken after a gastrograffin swallow which was performed to identify any oesophageal injuries. The bullet appears to be located just right of the L4 vertebral body. Having apparently crossed the midline in a clinically stable patient it is unlikely it is intraperitoneal. 5. What would be your management plan for this patient?
This patient requires further definitive investigation in the form of a CT abdomen with IV contrast. A DPL or Ultrasound would also be useful to determine the presence of free fluid, however would not necessarily identify the likely track of the bullet.

What happened next.. CT of the neck, chest and abdomen identified a high oesophageal injury and the bullet which was lodged in the patient’s right common iliac artery. On re-examination of the patient, he appeared to have no palpable pulses of his right lower limb. The patient had sustained a bullet embolus which had entered in the aortic arch and travelled through the

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systemic system until the vascular diameter was less than that of the bullet. The patient underwent a neck exploration and oesophageal repair. A bullet embolectomy via laparotomy was also performed. The patient underwent an uneventful post-operative course. Learning Points  All trauma patients require formal primary and secondary survey, otherwise occult injuries can easily be missed.  An odd number of bullet holes should ring alarm bells.  Bullet emboli are very rare and occur due to low velocity gunshot injuries. It is likely the bullet entered the aortic arch and subsequently resealed preventing ongoing haemorrhage which would have likely killed the patient before he reached casualty. Further Reading
Symbas, Harlaftis (1977) Bullet emboli in the pulmonary and systemic arteries. Ann Surg. March; 185(3): 318–320